E-211 Prior Approval Process

Prior to the provision of certain services, approval must be obtained from the Department. If charges are submitted for services that require prior approval and approval was not obtained, payment will not be made for services as billed. 

The Department will not give prior approval for an item or service if a less expensive item or service is considered appropriate to meet the patient's need. 

Prior approval to provide services does not include any determination of the patient's eligibility. When prior approval is given, it is the provider's responsibility to verify the patient's eligibility on the date of service. 

If a participant becomes enrolled in an MCO or MCCN during a period of time for which a prior approval has been previously granted, the prior approval will no longer be applicable, effective with the participant’s managed care enrollment date. Prior approval requests for participants in an MCO or MCCN should be directed to the individual plan.

E-211.1 Prior Approval Requests

Prior approval requests must contain enough information for Department staff to make a decision on medical necessity, appropriateness and anticipated patient benefits of the service.

The single most common reason for denial of prior approval requests is lack of adequate information upon which to make an informed decision.

The following items or services may be provided only with prior approval by the Department: 

• Binaural and/or monaural hearing aids and dispensing fees, if replacement is within three years of the initial or previous purchase. 

• Quantity limits are exceeded. 

• Supplies/Accessories not elsewhere classified. 

A prior approval request to provide hearing aids must be accompanied by the following:

• A copy of a Practitioner’s order, signed by the practitioner and dated within the past twelve months, to allow the hearing aids to be fitted. 

• The audiogram with the written recommendation. 

• Documentation that reflects the actual acquisition cost of the hearing aid(s) or supplier’s catalog price confirming acquisition costs.

Prior approval requests may be submitted to the Department by mail or fax.